Increased acute mortality with chemoradiotherapy for locally advanced head and neck cancer in patients ≥70years

Utilization and Impact of a Radiation Nursing Clinic to Address Acute Care Needs for Patients with Gynecologic Cancers

BACKGROUND

The risk factors for acute care utilization in gynecologic oncology patients are poorly understood. This study aimed to evaluate risk factors for the utilization of our centre's acute care radiation nursing clinic (RNC) by gynecologic oncology patients receiving radiotherapy (RT).

METHODS

This was a retrospective cohort study of gynecological cancer patients treated with RT at an academic cancer centre between 1 August 2021 and 31 January 2022. Data on socio-demographics, clinical and treatment characteristics, and RNC visits were collected and summarized by descriptive statistics. The Wilcoxon rank sum test and chi-squared test/Fisher's exact test were used for comparisons of continuous and categorical variables, respectively.

RESULTS

RT was delivered to 180 patients, of whom 42 (23%) received concurrent chemoradiation (CCR). Compared to those receiving RT alone, patients receiving CCR had higher rates of RNC utilization (55% vs. 19%, p < 0.001). Within the CCR cohort, patients who presented to the RNC were more likely to be unpartnered (43% vs. 11%, p = 0.04), receive a referral to Psychosocial Oncology (39% vs. 5.3%, p = 0.01), and experience treatment interruptions (52% vs. 16%, p = 0.02). There were no associations between RNC visits and age, disease site, or distance from the cancer centre.

CONCLUSIONS

The receipt of CCR and specific psychosocial risk factors were associated with increased RNC utilization. Targeted strategies and early intervention to better meet the supportive care and psychosocial needs of this vulnerable population are needed.

Machine Learning and Nomogram Prognostic Modeling for 2-Year Head and Neck Cancer-Specific Survival Using Electronic Health Record Data: A Multisite Study

PURPOSE

There is limited knowledge of the prediction of 2-year cancer-specific survival (CSS) in the head and neck cancer (HNC) population. The aim of this study is to develop and validate machine learning models and a nomogram for the prediction of 2-year CSS in patients with HNC using real-world data collected by major teaching and tertiary referral hospitals in New South Wales (NSW), Australia.

MATERIALS AND METHODS

Data collected in oncology information systems at multiple NSW Cancer Centres were extracted for 2,953 eligible adults diagnosed between 2000 and 2017 with squamous cell carcinoma of the head and neck. Death data were sourced from the National Death Index using record linkage. Machine learning and Cox regression/nomogram models were developed and internally validated in Python and R, respectively.

RESULTS

Machine learning models demonstrated highest performance (C-index) in the larynx and nasopharynx cohorts (0.82), followed by the oropharynx (0.79) and the hypopharynx and oral cavity cohorts (0.73). In the whole HNC population, C-indexes of 0.79 and 0.70 and Brier scores of 0.10 and 0.27 were reported for the machine learning and nomogram model, respectively. Cox regression analysis identified age, T and N classification, and time-corrected biologic equivalent dose in two gray fractions as independent prognostic factors for 2-year CSS. N classification was the most important feature used for prediction in the machine learning model followed by age.

CONCLUSION

Machine learning and nomogram analysis predicted 2-year CSS with high performance using routinely collected and complete clinical information extracted from oncology information systems. These models function as visual decision-making tools to guide radiotherapy treatment decisions and provide insight into the prediction of survival outcomes in patients with HNC.

Chemoradiotherapy but Not Radiotherapy Alone for Larynx Preservation in T3. Considerations from a German Observational Cohort Study

Simple Summary

For advanced laryngeal carcinoma, primary radiotherapy with or without chemotherapy (pCRT or pRT) is used as an alternative to total laryngectomy (TL) to preserve a functional larynx. For advanced laryngeal cancer (T4), poorer survival has been reported after nonsurgical treatment. Is there a need to fear worse survival in moderately advanced tumors (T3)? The outcomes after pRT, pCRT, or surgery were evaluated in 121 patients with T3 laryngeal cancers. pCRT and TL with risk-adopted adjuvant (chemo)radiotherapy (TL ± a(C)RT) yielded results without a significant survival difference. However, after pRT alone, survival was significantly poorer than after TL ± a(C)RT. Thus, according to our data and supported by the literature, pCRT instead of pRT alone is recommended for T3 laryngeal cancers. According to the literature, this recommendation also applies to bulky tumors (6–12 mm), vocal cord fixation, at least minimal cartilage infiltration, and advanced N stage. TL ± a(C)RT instead of larynx preservation should be considered if any of these factors is present and chemotherapy is prohibited; in cases with a tumor volume > 12 mm, severe forms of vocal cord fixation or cartilage infiltration; or when the patient needs a feeding tube or a tracheotomy before the onset of therapy.

Abstract

For advanced laryngeal cancers, after randomized prospective larynx preservation studies, nonsurgical therapy has been applied on a large scale as an alternative to laryngectomy. For T4 laryngeal cancer, poorer survival has been reported after nonsurgical treatment. Is there a need to fear worse survival also in T3 tumors? The outcomes of 121 T3 cancers treated with pCRT, pRT alone, or surgery were evaluated in an observational cohort study in Germany. In a multivariate Cox regression of the T3 subgroup, no survival difference was noted between pCRT and total laryngectomy with risk-adopted adjuvant (chemo)radiotherapy (TL ± a(C)RT) (HR 1.20; 95%-CI: 0.57–2.53; p = 0.63). However, survival was significantly worse after pRT alone than after TL ± a(C)RT (HR 4.40; 95%-CI: 1.72–11.28, p = 0.002). A literature search shows that in cases of unfavorable prognostic markers (bulky tumors of 6–12 ccm, vocal cord fixation, minimal cartilage infiltration, or N2–3), pCRT instead of pRT is indicated. In cases of pretreatment dysphagia or aspiration requiring a feeding tube or tracheostomy, gross or multiple cartilage infiltration, or tumor volume > 12 ccm, outcomes after pCRT were significantly worse than those after TL. In these cases, and in cases where pCRT is indicated but the patient is not suitable for the addition of chemotherapy, upfront total laryngectomy with stage-appropriate aRT is recommended even in T3 laryngeal cancers.

The impact of age on outcome in phase III NRG Oncology/RTOG trials of radiotherapy (XRT) +/- systemic therapy in locally advanced head and neck cancer

PURPOSE

To examine the role age plays in the treatment and prognosis of locally advanced head and neck cancer (LAHNC) treated definitively with radiation alone or combined modality therapy.

METHODS

A retrospective analysis was performed of three NRG/RTOG trials examining either radiation alone or combined radiation and systemic therapy for LAHNC. The effect of age (≥70 yrs.) on cause-specific survival (CSS), overall survival (OS), and toxicity was evaluated.

RESULTS

A total of 2688 patients were analyzed, of whom 309 patients (11.5%) were ≥ 70. For all studies combined, the hazard ratio (HR) for CSS for patients age ≥ 70 vs. those <70 was 1.33 (95%CI: 1.14-1.55, p < 0.001). For OS, the HR for patients age ≥ 70 vs. those <70 for all studies combined was 1.55 (95% CI 1.35-1.77, p < 0.001). After adjustment for all covariates, age ≥ 70 was associated with worse OS regardless of adjustment for smoking and p16 status. The survival difference was more pronounced in those receiving combined radiation and systemic therapy. Hematologic and renal toxicities were increased in combined modality trials in patients ≥70 years old.

CONCLUSIONS

Patients age ≥ 70 with LAHNC were underrepresented in these clinical trials. Their CSS and OS proved inferior to patients <70 years old.

Clinical characteristics, treatment methods and prognoses of patients with oral squamous cell carcinoma in Japanese population: a single institution retrospective cohort study

BACKGROUND

The status of oral cancer therapy in elderly patients in Japan, where ageing is rapidly progressing, may serve as a model for other countries with similar demographics. There is controversy over what kind of treatment should be applied and how aggressively it should be applied to very elderly patients who have exceeded the average life expectancy. Given that 85 years is approximately the overall Japanese life expectancy at birth, we considered a threshold of 85 years and hypothesized that the prognosis of oral squamous cell carcinoma (SCC) patients aged ≥85 years was not inferior to that of those < 85 years. The aim of the present study was to investigate the clinical characteristics, treatment methods, and prognoses of Japanese oral SCC patients aged ≥85 years.

METHODS

A retrospective cohort study was performed. The data of patients with primary oral SCC (n = 358) from 2005 to 2018 in our institute were extracted from electronic medical records. A total of 358 patients with oral SCC were divided into two groups (≥85 years group [n = 26] and < 85 years group [n = 332]) based on the age threshold of 85 years at the first visit. Kaplan-Meier survival analyses and Cox proportional hazard models were used to analyse overall survival (OS) and hazard ratios (HRs) according to age group, treatment, and TNM classification.

RESULTS

There was no difference in the 5-year OS rate between the ≥85 years and < 85 years groups (80.8% vs. 82.2%, P = 0.359). This finding was the same in the operative (94.7% vs. 85.8%, P = 0.556) and non-operative (42.9% vs. 33.2%, P = 0.762) groups, indicating that age did not affect prognosis. Mortality was lower in the operative group than in the non-operative group (adjusted HR: 0.276, 95% CI: 0.156-0.489, P < 0.001), suggesting that surgery is a superior method. However, non-surgical treatment was selected at a higher rate in the ≥85 years group (26.9% vs. 11.1%, P = 0.028).

CONCLUSIONS

This study suggests the prognosis of ≥85-year-old patients was not inferior to that of < 85-year-old patients. We recommend that surgery as the first choice treatment for ≥85-year-old patients with oral SCC who can tolerate surgery should be performed.

Understanding Nanoparticle Toxicity to Direct a Safe-by-Design Approach in Cancer Nanomedicine

Nanomedicine is a rapidly growing field that uses nanomaterials for the diagnosis, treatment and prevention of various diseases, including cancer. Various biocompatible nanoplatforms with diversified capabilities for tumor targeting, imaging, and therapy have materialized to yield individualized therapy. However, due to their unique properties brought about by their small size, safety concerns have emerged as their physicochemical properties can lead to altered pharmacokinetics, with the potential to cross biological barriers. In addition, the intrinsic toxicity of some of the inorganic materials (i.e., heavy metals) and their ability to accumulate and persist in the human body has been a challenge to their translation. Successful clinical translation of these nanoparticles is heavily dependent on their stability, circulation time, access and bioavailability to disease sites, and their safety profile. This review covers preclinical and clinical inorganic-nanoparticle based nanomaterial utilized for cancer imaging and therapeutics. A special emphasis is put on the rational design to develop non-toxic/safe inorganic nanoparticle constructs to increase their viability as translatable nanomedicine for cancer therapies.

Toxicity syndrome and early competing deaths in head-and-neck cancer undergoing radiation therapy: Observation and hypothesis

Radiotherapy (RT) and/or concurrent chemoradiation (CRT) is the mainstay for the treatment of locally advanced head-and-neck cancer (LAHNC). Sepsis remains a poorly understood and unrecognized event in head-and-neck cancer. The study aims to hypothesize a 'toxicity syndrome' leading to sepsis and subsequent sepsis-related deaths. A retrospective audit of all 125 LAHNC patients treated radically from January 2013 to June 2017 was conducted. A total of fifteen toxic deaths were reported. Thirteen deaths were attributed to sepsis. Individual toxicity for death was ascertained only for three cases. A toxicity syndrome namely 'mucositis-dysphagia-aspiration-sepsis (MDAS) complex' was proposed as the cause of death in the rest ten cases. The authors recommend the surveillance of the 'MDAS complex' for the prevention of early toxicity-related deaths in patients with LAHNC undergoing RT or CRT.

Competing Morbidities In Advanced Head And Neck Squamous Cell Carcinoma Concurrent Chemoradiotherapy: A Strong Implication Of A Multidisciplinary Team Approach

Concurrent chemoradiotherapy (CCRT) is the standard approach for the treatment of locally advanced head and neck squamous cell carcinoma. Despite its undisputed advantages, CCRT is associated with acute and late toxicities, leading to unfavorable implications (eg, unplanned interruptions and noncancer-related mortality). The former prolongs the overall treatment time leading to a detrimental effect on tumor control. The latter consists of several noncancer morbidities arising from treatment-related toxicities, identifying a new pathway in cancer fate. This pathway has been termed noncancer mortality or competing mortality and consists of a series of treatment-competing morbidities, which nullify all therapeutic efforts aimed at curing these patients. The management of patients with head and neck squamous cell carcinoma who experience treatment-related toxicities is complex and requires expertise in oncological treatment as well as supportive care. The optimal management of these patients should start with knowledge regarding the most important competing morbidities developing during all phases of the disease (ie, from diagnosis to follow-up) to minimize treatment interruptions, ensure appropriate psychological support, and achieve the best oncological result. The purpose of the present review is to analyze the most important competing morbidities due to patient’s condition at baseline and CCRT, which could result in noncancer mortality. A multidisciplinary team approach is strongly required in the management of this disease.

Helping hospital professionals to implement Advance Care Planning in daily practice: a European Delphi study from field experts

BACKGROUND

Advance Care Planning (ACP) communication is difficult to implement in hospital. Possibly this has to do with the fact that the concept is not well tuned to the needs of hospital professionals or that they experience implementation barriers in practice.

AIMS

The aim of this study was to investigate what is valued in having ACP conversations by hospital professionals (physicians, nurses, psychologists and social workers) and what they experience as barriers and facilitating factors for having ACP conversations with patients.

METHODS

A Delphi study consisting of two rounds with respectively 21 and 19 multidisciplinary experts from seven European countries was organised. Data were analysed using content analysis and descriptive statistics.

RESULTS

Participants agreed that ACP is valued mostly because it is seen to improve transmural continuation of care, emotional processing of the loss of a patient, and serenity at the end of life. Reported barriers are patient characteristics blocking patient-centred communication and a lack of knowledge to have these conversations. An important facilitator is multidisciplinary cooperation.

CONCLUSIONS

There is consensus by experts from different settings and countries suggesting that these results can theoretically be applied to hospital settings in Europe. This study reveals that hospital professionals value ACP in hospital practice, but that they encounter several barriers to its implementation.

Concurrent chemoradiotherapy for head and neck cancers in older patients: Outcomes and their determinants

INTRODUCTION

Meta-analyses have shown concurrent chemoradiotherapy (CCRT) provides no survival benefit over radiotherapy in patients of head and neck squamous cell carcinoma (HNSCC) aged over 70 years. This study was performed to determine the adverse-effect profile, compliance, functional and oncological outcomes in patients of HNSCC over 70 years of age treated with CCRT.

MATERIALS AND Methods

Retrospective analysis of stage III/IV HNSCC in patients above 70 years of age who received CCRT at our institution (n = 57). Cox-proportional hazards regression model was used for statistical analysis.

RESULTS

There were 57 patients of stage III/IV HNSCC who underwent curative CCRT. 61% completed chemotherapy with no deaths and acceptable toxicity. The predictors of recurrence were poorer performance status (P = 0.031) and treatment breaks (P = 0.04). Tube dependence was associated with 2.7 times higher risk of mortality (P = 0.005).

CONCLUSION

CCRT should be considered standard of care in those over seventy with good performance status. Patients with tube dependence have a higher risk of persistent disease or treatment related mortality.

Organ preservation for advanced larynx cancer: A review of chemotherapy and radiation combination strategies

The larynx is an organ of the upper aerodigestive tract that is involved in many critical functions such as breathing, speaking, and swallowing. As a result, both larynx cancer and its treatment may significantly affect quality of life. The management of laryngeal cancer has focused on improving survival while preserving the function of the organ. This manuscript focuses on the use of chemotherapy and radiation therapy as a non-surgical approach and potential organ preservation strategy for patients with advanced larynx cancer. We review the key clinical data on the following treatment courses: (1) induction chemotherapy followed by definitive radiation therapy, (2) concurrent chemotherapy and radiation, and (3) induction chemotherapy followed by concurrent chemo-radiation. We also review the clinical data on organ preservation for patients with hypopharynx cancers. Results from phase III studies suggest that patients with advanced T4 cancers have better outcomes with a primary surgical approach, while for patients with T2N+ and T3 tumors, definitive concurrent chemotherapy and radiation or induction chemotherapy followed by definitive radiation therapy are acceptable options. Choosing the optimal treatment strategy depends on patients' desires, tumor extent, and adequate follow-up to detect early recurrences in cases of larynx preservation treatments. To proceed with an organ preservation strategy, the patient should have a good pre-treatment larynx function, and there must be a high level of skill and cooperation among various disciplines.

Managing older patients with head and neck cancer: The non-surgical curative approach

Managing older patients with head and neck cancers poses a challenge due to the often reduced levels of physiological reserve, the frequent comorbidities and treatment related toxicity. These factors have implications on speech, breathing and swallowing functions. Treatment management plans in these patients may result in de-intensification strategies and as a result of this, use of non-standard treatments is increasing. There have been published reports that indicate the addition of concurrent systemic therapy to radiation in selected older patients is feasible, and produces outcomes comparable with younger patients. However, some other studies including meta-analyses suggest a lack of real survival benefit with the addition of chemotherapy. So, the key point appears to be the optimal patient selection. Appropriate geriatric and frailty assessments are required to help determine the optimal treatment for older patients with head and neck cancer. Treatment for this population still needs to be well defined and optimized in both modality and intensity. Qualitative studies are also required to address short and long-term post-treatment quality-of-life and survivorship issues in this specific patient population. This review summarizes the evidence available regarding the non-surgical management of older patients with head and neck cancers.

The Changing Paradigm of Radiotherapy in the Elderly Population

There is increasing awareness of the special needs for care of the elderly cancer patient. Newer precise conformal radiotherapy techniques allow the safe delivery of higher doses of radiotherapy to the target tumor while reducing the dose to surrounding critical organs. This has led to a shortening of radiotherapy protocols for both curative and palliative indications. We review these novel techniques and protocols and the published clinical studies that include elderly patients treated with these techniques. Despite the fact that the elderly are a growing significant proportion of cancer patients, and the need for radiotherapy in the elderly is expected to rise with increasing life expectancy, they are underrepresented in most clinical studies of radiotherapy, and there are few studies specifically investigating radiotherapy in the elderly. The treatment of early-stage primary lung cancer with stereotactic body radiotherapy is a prime example how new highly conformal techniques and shortened treatment protocols are changing the approach to radiotherapy in the elderly. With improved imaging and radiotherapy treatment precision, it is expected that such techniques will become increasingly used in other cancer sites. It is important for radiation oncologists to be aware of the special needs of the elderly cancer patient and in particular to assess these patients based on functional status and not only chronological age. In addition, geriatric oncologists should be aware of modern radiotherapy techniques that can be particularly appropriate for the elderly patient.

Managing an Older Adult with Cancer: Considerations for Radiation Oncologists

Older adults with cancer present a unique set of management complexities for oncologists and radiation oncologists. Prognosis and resilience to cancer treatments are notably dependent on the presence or risk of "geriatric syndromes," in addition to cancer stage and histology. Recognition, proper evaluation, and management of these conditions in conjunction with management of the cancer itself are critical and can be accomplished by utilization of various geriatric assessment tools. Here we review principles of the geriatric assessment, common geriatric syndromes, and application of these concepts to multidisciplinary oncologic treatment. Older patients may experience toxicities related to treatments that impact treatment effectiveness, quality of life, treatment-related mortality, and treatment compliance. Treatment-related burdens from radiotherapy are increasingly important considerations and include procedural demands, travel, costs, and temporary or permanent loss of functional independence. An overall approach to delivering radiotherapy to an older cancer patient requires a comprehensive assessment of both physical and nonphysical factors that may impact treatment outcome. Patient and family-centered communication is also an important part of developing a shared understanding of illness and reasonable expectations of treatment.

Adjuvant chemoradiation does not improve survival in elderly patients with high-risk resected head and neck cancer

OBJECTIVES/HYPOTHESIS

Randomized trials have demonstrated that adjuvant chemoradiotherapy (CRT) confers an overall survival (OS) benefit over adjuvant radiation therapy (RT) alone in patients with resected head and neck squamous cell carcinoma (HNSCC) with adverse pathologic features (positive surgical margins [SM+] and/or extracapsular extension [ECE]). Whether this OS benefit exists in an elderly population remains unknown.

STUDY DESIGN

Retrospective database study.

METHODS

Using the National Cancer Database, we identified 1,686 elderly patients (age ≥70 years) with resected HNSCC with SM+ and/or ECE, who received adjuvant CRT (491 patients, 29%) or adjuvant RT alone (1,195 patients, 71%) between 1998 and 2011. Three-year survival rates were estimated using the Kaplan-Meier method both before and after propensity score matching (PSM). Crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using Cox regression modeling.

RESULTS

Median follow-up was 23.5 and 42.8 months for all and surviving patients, respectively. Three-year OS was 50.7% and 44.4% among patients receiving adjuvant CRT and RT alone, respectively (P = .002). On multivariate analysis, there was no significant improvement in OS with adjuvant CRT relative to adjuvant RT alone (HR: 0.88, 95% CI: 0.73-1.06). Similarly, a PSM cohort showed no significant difference in the 3-year OS for patients receiving adjuvant CRT versus adjuvant RT alone (48.8% and 50.9%, respectively; P = .839).

CONCLUSIONS

Although the addition of chemotherapy to adjuvant RT has been proven effective in randomized trials of patients with resected HNSCC with SM+ or ECE, it may be less efficacious in an elderly patient population treated outside of a controlled trial setting.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:831-840, 2018.

Assessment and management of radiotherapy induced toxicity in older patients

Radiotherapy is an attractive treatment option for older adults, especially where surgery and chemotherapy pose too great a risk. Radiotherapy toxicity may be divided into acute/early and late effects of treatment. The latter may have limited relevance to an older patient with competing causes of mortality due to significant comorbidity. Altered fractionation regimes have been employed in numerous sites, with no significant toxicity impact. These offer greater convenience in the elderly, especially those with limited social support or in active caregiving roles. As radiotherapy toxicity is site specific, it's important to assess baseline function via Comprehensive Geriatric Assessment (CGA), and any pre-existing comorbidities that may influence toxicity. With modern radiotherapy technology and capabilities, these are less of an issue and radiotherapy is a very suitable treatment option for the older adult. When evaluating the literature on toxicity in older patients, it's important to recognise that older studies do not represent modern day radiotherapy techniques and capabilities. Advanced technology may simultaneously deliver enhanced target coverage and reduced toxicity. More research is required related to the predictive power of CGA in linking radiotherapy toxicity to frailty. What little evidence exists shows that CGA has a role in treatment of older patients with radiotherapy and that, in general, radiotherapy appears to be well tolerated in older adults. The purpose of this review is to provide a broad overview of the mechanisms of normal tissue reactions to radiotherapy and how radiation induced toxicity may affect older patients.

Poly-(ADP-ribose)-polymerase inhibitors as radiosensitizers: a systematic review of pre-clinical and clinical human studies

BACKGROUND

Poly-(ADP-Ribose)-Polymerase (PARP) inhibitors are becoming important actors of anti-neoplasic agents landscape, with recent but narrow FDA's approvals for ovarian BRCA mutated cancers and prostatic cancer. Nevertheless, PARP inhibitors are also promising drugs for combined treatments particularly with radiotherapy. More than seven PARP inhibitors have been currently developed. Central Role of PARP in DNA repair, makes consider PARP inhibitor as potential radiosensitizers, especially for tumors with DNA repair defects, such as BRCA mutation, because of synthetic lethality. Furthermore the replication-dependent activity of PARP inhibitor helps to maintain the differential effect between tumoral and healthy tissues. Inhibition of chromatin remodeling, G2/M arrest, vasodilatory effect induced by PARP inhibitor, also participate to their radio-sensitization effect.

MATERIALS AND METHODS

Here, after highlighting mechanisms of PARP inhibitors radiosensitization we methodically searched PubMed, Google Scholar, Cochrane Databases and meeting proceedings for human pre-clinical and clinical studies that evaluated PARP inhibitor radiosensitizing effect. Enhancement ratio, when available, was systematically reported.

RESULTS

Sixty four studies finally met our selection criteria and were included in the analysis. Only three pre-clinical studies didn't find any radiosensitizing effect. Median enhancement ratio vary from 1,3 for prostate tumors to 1,5 for lung cancers. Nine phase I or II trials assessed safety data.

CONCLUSION

PARP inhibitors are promising radiosensitizers, but need more clinical investigation. The next ten years will be determining for judging their real potential.

Rethinking cancer nanotheranostics

Advances in nanoparticle synthesis and engineering have produced nanoscale agents affording both therapeutic and diagnostic functions that are often referred to by the portmanteau 'nanotheranostics'. The field is associated with many applications in the clinic, especially in cancer management. These include patient stratification, drug-release monitoring, imaging-guided focal therapy and post-treatment response monitoring. Recent advances in nanotheranostics have expanded this notion and enabled the characterization of individual tumours, the prediction of nanoparticle-tumour interactions, and the creation of tailor-designed nanomedicines for individualized treatment. Some of these applications require breaking the dogma that a nanotheranostic must combine both therapeutic and diagnostic agents within a single, physical entity; instead, it can be a general approach in which diagnosis and therapy are interwoven to solve clinical issues and improve treatment outcomes. In this Review, we describe the evolution and state of the art of cancer nanotheranostics, with an emphasis on clinical impact and translation.